Tuberculosis recovery in Georgia: implementing more by 24
Authors: Nana Kiria, Nino Lomtadze, Nelly Solomonia, Rusudan Aspindzelashvili, Maka Danelia, Irakli Gabisonia, Marina Janjgava, Irma Khonelidze, Maia Kipiani, Nestani Tukvadze, Henry M Blumberg, Russell R Kempker, Jennifer Furin, Zaza Avaliani
Journal: The Lancet Infectious Diseases (2022)

The 2022 Global Tuberculosis Report released by WHO again contained more bad news: diagnoses are not slowing enough to meet WHO's End TB strategy, and deaths from the disease continue to increase.1WHOGlobal TB Report 2022.https://www.who.int/teams/global-tuberculosis-programme/tb-reportsDate: October, 2022Date accessed: October 27, 2022Google Scholar Although the COVID-19 pandemic has adversely affected global efforts to eliminate tuberculosis, even before the pandemic the tuberculosis community was not on track to meet any indicators set at the 2018 United Nations High-Level Meeting on Tuberculosis.2Pai M Kasaeva T Swaminathan S COVID-19's devastating effect on tuberculosis care—a path to recovery.N Engl J Med. 2022; 386: 1490-1493Crossref PubMed Scopus (122) Google Scholar These bleak statistics come at a time of scientific tuberculosis breakthroughs. Shorter, safer, and more effective regimens are now available for the prevention and treatment of the disease.3Swindells S Ramchandani R Gupta A et al.One month of rifapentine plus isoniazid to prevent HIV-related tuberculosis.N Engl J Med. 2019; 380: 1001-1011Crossref PubMed Scopus (219) Google Scholar, 4Turkova A Wills G Wobudeya E et al.Shorter treatment for non-severe tuberculosis in African and Indian children.N Engl J Med. 2022; 386: 911-922Crossref PubMed Scopus (92) Google Scholar, 5Dorman S Nahid P Kurbatova E et al.Four-month rifapentine regimens with or without moxifloxacin for tuberculosis.N Engl J Med. 2021; 384: 1705-1718Crossref PubMed Scopus (230) Google Scholar, 6Médecins Sans FrontièresTB PRACTECAL.https://msf.org.uk/tb-practecalDate accessed: September 6, 2022Google Scholar These improved regimens need to move quickly from WHO recommended policy into people affected by tuberculosis. This urgency has prompted the launch of the 1/4/6×24 campaign (panel). This effort, inspired by the legacy of the late Dr Paul Farmer, urges tuberculosis actors to implement the necessary staff, stuff, spaces, systems, and support to roll out these treatments by the end of 2024.7Treatment Action Group1/4/6x24 campaign launched to rally energy, political will, funding needed to fight tuberculosis.https://www.treatmentactiongroup.org/statement/1-4-6-x-24-campaign-launched-to-rally-energy-political-will-funding-needed-to-fight-tuberculosis/Date accessed: September 6, 2022Google ScholarPanelComponents of the 1/4/6×24 campaign•Roll-out of the recommended 1-month daily regimen of isoniazid and rifapentine or the recommended once-weekly, 3-month regimen of isoniazid and rifapentine for tuberculosis preventive therapy•Roll-out of the 4-month regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol for children with non-severe tuberculosis or the 4-month regimen of isoniazid, rifapentine, pyrazinamide, and moxifloxacin for adolescents and adults with drug-susceptible tuberculosis•Roll-out of the 6-month regimen of bedaquiline, pretomanid, linezolid, and moxifloxacin for adolescents and adults with drug-resistant tuberculosis•Provision of the systems and support needed for optimal scale-up of these regimens•Availability of all these regimens for most people affected by tuberculosis worldwide by Dec 31, 2024 •Roll-out of the recommended 1-month daily regimen of isoniazid and rifapentine or the recommended once-weekly, 3-month regimen of isoniazid and rifapentine for tuberculosis preventive therapy•Roll-out of the 4-month regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol for children with non-severe tuberculosis or the 4-month regimen of isoniazid, rifapentine, pyrazinamide, and moxifloxacin for adolescents and adults with drug-susceptible tuberculosis•Roll-out of the 6-month regimen of bedaquiline, pretomanid, linezolid, and moxifloxacin for adolescents and adults with drug-resistant tuberculosis•Provision of the systems and support needed for optimal scale-up of these regimens•Availability of all these regimens for most people affected by tuberculosis worldwide by Dec 31, 2024 One country that is leading efforts in the Do More by 2024 initiative is Georgia. Considered until 2016 to have a high burden of drug-resistant tuberculosis, Georgia has welcomed innovation over the past decade to achieve all End TB targets. The country has reduced the incidence of both tuberculosis and drug-resistant tuberculosis by 50% since 2015,8WHOTuberculosis profile: Georgia.https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22GE%22Date accessed: September 6, 2022Google Scholar improved the success rates of treatment for all forms of tuberculosis, and enhanced tuberculosis research infrastructure.9Kiria N Avaliani Z Chinchaurali M Mikiashvili L Trends in tuberculosis notification and treatment in Georgia.Eur Respir J. 2020; 56: 460Google Scholar Successful implementation of the 1/4/6×24 campaign requires action in each area of the WHO End TB strategy: bold policies and supportive systems; integrated, patient-centred tuberculosis care and prevention; and intensified research and innovation. In terms of policies and systems, Georgia has updated and adapted its national tuberculosis guidelines and training materials to include all new WHO recommendations, and patients who have survived tuberculosis have a key role. Georgia has also recently launched quality-improvement projects on person-centred care, pivoting towards a tuberculosis-elimination model based on their successful hepatitis C elimination programme.10Averhoff F Shadaker S Gamkrelidze A et al.Progress and challenges of a pioneering hepatitis C elimination program in the country of Georgia.J Hepatol. 2020; 72: 680-687Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar For integrated, patient-centred services, the country has procured the diagnostic supplies and medications needed to promote the newly recommended regimens, including child-friendly formulations. Adaptations are also being made for more family-friendly care for tuberculosis, such that paediatric tuberculosis can be diagnosed early and the 4-month regimen for non-severe tuberculosis can be initiated. Georgia has deployed a robust programme for addressing social needs. With the programmatic implementation of new tuberculosis drugs (bedaquiline and delamanid) since 2015; further implementation of all-oral, longer and modified shorter treatment regimens since 2019; and video supported treatment; Georgia has improved the treatment success rate for drug-resistant tuberculosis from less than 50% before 2015 to 78% for the 2019 cohort. Georgia also offers quality testing to populations at high risk of tuberculosis using digital radiography and computer-aided detection. This testing has improved active tuberculosis case finding and allowed high-risk people who do not have tuberculosis disease to be offered shorter preventive therapy. Peer consultants and civil society organisations are involved in all aspects of supportive patient care. Finally, the Georgian National Center for Tuberculosis and Lung Diseases is a well recognised site for applied research. Collaborations with international academic institutions and research centres have cultivated the next generation of Georgian tuberculosis investigators.11Kempker R Tukvadze N Sthreshley L et al.The impact of a Fogarty International Center-supported tuberculosis training program in the country of Georgia.Am J Trop Med Hyg. 2018; 98: 1069-1074Crossref PubMed Scopus (8) Google Scholar These partnerships have built human capacity and infrastructure, allowing translation of research into policy and practice. Progress has been impressive, but Georgia is at a precarious moment in its tuberculosis efforts, especially in the face of decreasing revenue owing to lower patient numbers. Continued financial and human resource investment is needed to ensure that Georgia continues its promising path. As one of the first countries to fully implement the 1/4/6×24 campaign, Georgia will move closer to meeting the End TB goals than most other settings, provided that sufficient investments are made. We hope that the country's swift and decisive actions in this regard will encourage others to follow suit. MK, NT, HMB, and RRK receive grant funding from the US National Institutes of Health, Emory-Georgia TB Research Training Program (grant number D43TW007124). Some of the work discussed in this Comment was supported by this grant. JF receives grant funding from the Stop TB Partnership's Global Drug Facility.